Awake prone positioning (APP) has gained prominence as a therapeutic intervention for acute respiratory distress syndrome (ARDS), particularly in COVID-19-related respiratory failure due to its proven survival benefits [1, 2]. However, the clinical applicability of APP in non-COVID-19 ARDS populations remains controversial, with patient tolerance and heterogeneous lung recruitment responses posing significant challenges [3]. To address these limitations, electromagnetic impedance tomography (EIT)—a non-invasive, radiation-free imaging modality—provides dynamic regional ventilation monitoring through real-time bedside visualization of pulmonary impedance changes [4]. We illustrate the integration of EIT-derived ventilation mapping to guide personalized positioning strategies in a non-intubated patient with moderate ARDS, demonstrating its potential to optimize alveolar recruitment while mitigating positional intolerance.
Key Points
- Challenges of Awake Prone Positioning in Non-COVID ARDS: While prone positioning is a well-established intervention in intubated ARDS patients, its benefits in non-intubated cases vary due to discomfort, positional intolerance, and inconsistent lung recruitment.
- Use of Electrical Impedance Tomography (EIT): EIT is a non-invasive, radiation-free bedside tool that provides real-time visualization of lung ventilation, enabling the identification of optimal positioning strategies.
- Case Presentation and EIT-Guided Positioning: A 61-year-old female with chemotherapy-induced lung toxicity developed Pneumocystis jirovecii pneumonia (PCP)-associated ARDS. Standard APP was poorly tolerated, prompting the use of EIT to guide alternative positioning.
- “Thinker’s Position” as an Alternative to Standard Proning: EIT analysis identified the “Thinker’s Position” as the most effective for improving oxygenation (SpO₂/FiO₂ ratio) and respiratory effort while minimizing discomfort.
- Objective Monitoring of Oxygenation and Ventilation Indices: EIT showed that both the prone position and “Thinker’s Position” improved end-expiratory lung volume (EELV), but the latter was better tolerated, allowing for prolonged use.
- Comparing Different Positions: The global inhomogeneity (GI) index, a marker of uneven lung ventilation, was lowest in the prone position, followed by the “Thinker’s Position.” However, the patient’s ability to sustain the prone position was limited.
- Successful Weaning from HFNC: The patient maintained the “Thinker’s Position” for approximately 6 hours per day, leading to progressive respiratory improvement and successful weaning from HFNC after 12 days.
- Impact on Respiratory Rate and ROX Index: Despite initial variability, the patient’s respiratory rate gradually stabilized, and the ROX index—an indicator of HFNC success—improved over time, reinforcing the effectiveness of EIT-guided positioning.
- Avoiding Discomfort-Induced Hypoxia: The patient’s attempt to return to standard proning on day 3 resulted in significant discomfort and worsening hypoxia, further supporting the need for individualized positioning approaches.
- Future Implications for ARDS Management: The findings highlight the potential of EIT as a precision tool for guiding APP strategies in non-intubated ARDS patients, reducing unnecessary discomfort while optimizing lung recruitment.
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